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NO2 'IN W'dl8 l l�1OZ Ol 'Gad,.aWil Pani aaa�' <br /> CITE'OF MAUR—CAW CF Moto <br /> WASTE HAUI,ER'S SOURCE CERTIFICATT <br /> 1. ODUCER OF LIOUP WASTE PH <br /> PICK-UP ADDREs s_ 1 C)'�, C� S a r t f �����,2 <br /> Number stmt city State z <br /> WASTE SOURCE: DOMESTIC WASTEWATER ONLY from 'ele one <br /> �( ptic Teak Portable Toilet <br /> PICK UP DATE�' TIME QUAN'T'ITY 00galsI <br /> I certify that this waste was delivered to-the bawler named below for 71egal_disp�osal at th�indicaPrinted N e of Owner,�Dccupant or Agent gma "' cc pant or en <br /> . I <br /> 2. ULER <br /> NAME Rotoootcr ,e <br /> BUSINESS ADDRESS 7 ) <br /> Number Street City State exp <br /> I certify that the described waste was hauled by me to the disposal facility named below. <br /> Receiving Station Permit No. Vehicle License No.�� <br /> Printer!Name of Rattler - Signature <br /> of]uiair <br /> 3. RECEIVING STATION <br /> i <br /> NAME AND ADDRESS_ Ci f Manteca W <br /> h'oQCF 2450 West"Yosemite Ave. Manteca,,CA 95337 <br /> I certify that the hauler above delivered the described liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of tlae Receiving Station Permit. <br /> Signature of Waste Facility Operator <br /> DATE _ TIME IK TIME OUT NET QUANTITY <br /> __gals <br /> ,i <br /> - i <br /> P--.02/09 office assistauVfo®s <br /> 'd tiLBI 'oN Wd88 ll SIE Ol 'qad <br />